Wake_Well Abandonment_20240903 (7)

WELL ABANDONMENT RECORD far lruneil(sc ONI
This form can he used for single or niulliple wells
1.Well Contr'acmr Infnrrutatios W'El.l.ABANbONMENT DETAII ti
Scott Hunt, Jr 71L Number of vii lls beiag abandoned: 1
Welt C•omractor Name roe well owner personally ahiantioms;we0 on h z;het propen)i F.v "Idork inletlo", w .ern-,rarer sMpfdi self, C/%0 erh IN. "Mite
r r.m row r.••Ni•d•arrhornrr nr �•a. arr whnur wr. Krnn
4561A
NC Well CommunrCertifrcalionNntnbtx 7Ir.:\pproXim,rlctnlunrc tot'Nalet'rrmaminfinwrll(%i9 (�)
SAEDACCO FOR%%.%rF.RSl'PPI l RFL1SONLY: `
ConVw Nam lc.Trpr of disinfectant u,rd:
2.Well Ce�tttictbn Perok M:, •1 = �
l.i.,t al!rppfkahk reel)prnnlEY n.r.l WM.S7rMe.1 Jn.rwc'f lnraarxnt rrc.r tJAlerrn 74L Atrtrunt of disinfectant u.cd:
3.Well use(check n ell usel:
Water Supld}Well: 7e.Sealing materials used(check all rhar apph):
❑Apriculurral ❑MunkipalTublic 3 Neat('cmcru Groat f I Rertomtc C'htpc or Pclicts
O(ieotherral(Heating.+C'oolinr Supph i ❑Residential Water Supply(single) ❑ Sand Crmat(,rant ❑ Dn(la%
❑Irdasinal:Comnrcrcial ❑Rcsidcrtt.•d Water St"Itt,(shared) ❑ Concrete Grout ❑ Drill Cutnnps
❑hri •uun ❑ Spec'ialh Gfoul ❑Grate)
Non-Water Supph Rcll: tJ Rentonite Slum I I Ottret(expla t under 7p
1119MUtnlonnL ❑Rtxocrn
lujoctinn«'ell: 7f.For each material selected abotc,prvitidi•amount of materials used:
❑AqudcrRechirge ❑GroutdwaaetRemediation Neat Cem. :941b ,Wtr:7gal. _ Sand Cem. :lb ,Wtr:gal.
❑Aquifer Storage and Recrn err ❑Sahmh barrier
❑Aquifer Teat ❑Stonmtaler Urerraer
❑Ey erintemal l eclmnlogn ❑Subsidence C'onitul 7g,Prot ide A brief description of the abanthnnnent procedure:
❑Geolliemal(Closed Loop ❑Tracer
location was over drilled and pvc was removed from boring;
❑Geothemal IFleaun +Conlin Retum) f](lthcr(cc am under 7 ) —
tremie grout location from bottom to top
4.DulteWed(sl Ahandaucd: 8-7-24
Sa.Wed location:
Brownfield Road Landfill
Facility"%ncr Nara Fxilwc 1DN(if apirl..abk) S.CHtifkadion:
i
2600 Brownfield Rd. Raleigh, NC 27610 8/7/2024
Ph,sical.Address.Cit).ad Zip :•ib<.'•rn:it!'i t-r:n.:d Well C autrxAut err well(hirer Dare
Wake !fy signing Ihes
R � Jrwrnr 1 hereby crrnJ►,that the wears) was(Meru uhurirknirr!ui
C'auni> Parcel Iderdrair.•.0 Na 4Jr1\, ocrvrihnitz with IJA.VC.4C 0IC'.0100 or 2C 0.1W R'rllConshwrtion."6rnekir(A
mid that a cYrp of fins term-3Ism been p mail l to the well owner.
Sh.Latitude and Inngitudc in(legrccumiuutrs.rcands nr decimal dtygnrs:
tit well field mie L•11.10ug ft millwwrt. 9.Site diagram or additional well details:
You uiai tee the back of this page to ptcnde additional well site details or%tell
abatdunmcrN drtaib. 1'(w ntal, afsu atach A Waroral pages if nctrssan
('O_NSTRLCTION DETAILS OF\\Ell ilt IIIANG AB\NDONh:D SCRM ITT 41.INSTRUCTIONS
.i(laclr MIN u.as),tio i rt•,ord+:it a,,x V,k •.r rrru:ci•ir o.< e•,rr ire r*,,trn a r rmppft - _
"rily ONLYwi(A the.momr LiAnom mmer,#nAr mmei.mcanahmaroesperm. 10a. For All Welt: Submit this form uithtn ;0 dais of compleron of tetll
6a.%-ell 1Die:
P-23 abardonmem to the followmG
Diiisitio of%titer RestrurcLs.Information Processing Unit.
1617 Mail Sersice('enter,Raleigh.T%C 27699-1617
6b•Total well depth: 20 4ft.)
lob.For Iulectiou Wills: fit addition to seidnmg the form to the addtess tit lu:i
abuts. also submit otic colr of this form wnhiti in days of completion of hell
6c.Borehole diameter:2 Iin.m abandonnient to the follouui4
Di%ision of Water Resources,Undergroved InjnYion(on(nrt Pnigram,
fed,Water leer)hrinw •nvund siirfacr. 10 (fish 1636 Mail%mice Center.Rakich,NC 276)9-1636
Inc. For W"ter Suunih & 1nkYti(in Wells: In iddinon to sending the form to
6c.Outer ca.ung length 4iflaowu): (h.l the addrrssr st abuse. also subnnt one cop% of this form aithitt to hits of
completion of well abandonment to the courih health dcpanniett of the writ}
6f.Innrrcasing'tubing length(if I:nnw where aticindonedni: hits)
6g.Scorn length(if know n is (fish
Fortin GW-an NonhCarohm Dquititi ito of Ern inlnniera aid Natatal Rcsotaces-Do ision of Water R osourcrs Re,iced August Vtl+